Healthcare Provider Details

I. General information

NPI: 1619045309
Provider Name (Legal Business Name): ALTITUDE PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 FAIRVIEW AVE STE 410
CALDWELL ID
83605-5424
US

IV. Provider business mailing address

1906 FAIRVIEW AVE STE 410
CALDWELL ID
83605-5424
US

V. Phone/Fax

Practice location:
  • Phone: 208-454-9839
  • Fax: 208-454-0727
Mailing address:
  • Phone: 208-454-9839
  • Fax: 208-454-0727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SEAN R WEATHERSTON
Title or Position: PRESIDENT
Credential: PT
Phone: 208-454-9839